Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101YM0800X | Mental Health Counselor | 89378 | CA |
N | 225C00000X | Rehabilitation Counselor |
NPI | 1235500091 |
---|---|
Provider Name | Amanda Martin |
First Address | San Dimas, CA 91773-3505 |
Second Address | San Dimas, CA 91773 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 19/10/2015 |
Last Update Date | 17/07/2019 |